Blood Transfusion Costs

In mid-November 2016, the United States Food and Drug Administration announced that it now requires all blood banks in the country to test for Zika virus in blood donations. Many banks have already begun complying, and results suggest that Zika prevalence remains extremely low in the United States — of the 800,000 donations evaluated since May, only about 40 have tested positive for the virus (and several of these have since been deemed false positives).

Good news for Americans, then. And there’s also good news for the rest of the world: On November 18, the World Health Organization declared that Zika is no longer a “public health emergency of international concern,” a status granted to only the most urgent public health issues. Nevertheless, the damage Zika has done — and will continue to do — to communities and economies, remains significant. The World Bank estimates that Zika will cost Latin America and the Caribbean about US $3.5 billion in 2016 alone, excluding the revenue lost from decreased tourism1.

If the epidemic, and its economic costs wane over time, one Zika-associated cost is sure to remain in the United States: testing blood donations for the virus. The FDA’s announcement brings attention to the costs associated with blood donation. It also highlights global problems with the cost and misuse of blood supply that need to be addressed to keep up with increasing demand.

Blood transfusion is extremely common in the United States, and the demand for blood increases every year. One in seven hospitalized patients requires blood. In 2006, about 15 million units of blood were transfused in American hospitals2. (A “unit” is defined as 525 milliliters of blood, which is roughly equal to one pint. An average adult has around nine to ten pints of blood in their body.) By 2011, the number of transfusions in the United States had risen to about 21 million units, at a cost of about US $210 per unit of blood transfused to the hospital 3. The cost to individual patients varies greatly depending on how and why the blood is used; for patients receiving organ transplants, the cost of blood alone can easily exceed US $38004. The demand for blood worldwide is also on the rise. For instance, China’s demand for blood in 2015 was in excess of 8000 tons. That equates to about three Olympic-sized swimming pools’ worth of blood5.

When an individual donates blood, a large number of small expenses go into testing, preserving, transporting, and eventually using the blood on a patient who needs it. These small expenses add up to the large cost per unit of blood that we see today4. Both the donor and the patient must be tested for blood group compatibility — different individuals belong to different blood groups, and transfusions are only safe between individuals of certain blood groups. All blood samples must also be tested for a set of pathogens, which includes HIV, Hepatitis B and C, West Nile Virus, and, as of last week, Zika Virus. Hospitals also incur costs for transportation and supplies associated with drawing and transfusing blood. New “risk mitigation” technologies, which seek to make blood transfusion as safe as possible, also add to costs.

Blood transfusion costs are high in the United States accounting for about 1% of hospitals’ budgets. They are, however, astronomical in low and middle-income countries. In 2013, one unit of blood cost about US $120 in Zimbabwe, which represents one eighth of the country’s GDP per capita.6 The reasons for high costs of blood in low and middle-income countries are the same as those for the high cost of blood in countries with robust health infrastructures like the United States: testing, transportation, storage, transfusion, and material and labor costs. Add to this an ever-increasing list of pathogens for which blood needs to be tested, and it is easy to see how costs increase. In fact, the never-ending demand for blood transfusions should be one of the major motivations for finding rapid, inexpensive diagnostic tools for existing and emerging infectious diseases; testing for Zika alone costs up to $10 per unit of donated blood.

Blood bank transfusion bags, each of a different blood grouping. Source: Wellcome Images.

Another crucial caveat to the high cost of blood donation is the misuse of the blood supply. Doctors in the United States tend to overprescribe blood transfusions, often to the detriment of patient health. In 2009, Stanford Hospital and Clinics, seeking to reduce expenses, implemented an online system that required doctors to review the guidelines for transfusion before approving a patient’s order of blood. This simple reminder decreased the number of blood transfusions at the hospital by 24%, saving the hospital an estimated US $1.6 million annually from its US $7 million blood-purchasing budget. Even more encouraging was the effect that this system had on patient outcomes. Among patients who received blood transfusions during their stay at the Stanford Hospital, the mortality rate decreased from 5.5% to 3.3%, and the length of stay decreased from 10.1 days to 6.2 days.7 Although other factors such as improved transfusion technologies probably contributed to the dramatic improvement in patient health, the Stanford intervention indicates that better use of the blood supply can be a win-win situation. Patients generally face better prognoses in the clinic and hospitals save big on costs.

The recent FDA ordinance to test all blood donations in the US for Zika is yet another step towards creating a blood supply that is safe and robust enough to keep up with increasing demand. This is undoubtedly a positive step. Generating a blood supply that is both safe and affordable, however, will take more than testing for pathogens. Researchers need to develop new, cheaper tools to perform all tests that are already required along the blood transfusion pipeline, and the Stanford intervention indicates that hospitals need to reassess standard blood transfusion practices. With a rising blood demand across the world, officials need to take a global outlook when implementing their solutions.

Colin Hemez is a junior in Ezra Stiles College majoring in Biomedical Engineering and Art History. He can be contacted at colin.hemez@yale.edu